Impact of Sofosbuvir-Based Therapy on Liver Transplant Candidates with Hepatitis C Virus Infection.

BACKGROUND: Sofosbuvir use in patients with decompensated cirrhosis may be associated with reduced liver transplant waitlist mortality and reduced need for transplant. METHODS: Data from the Scientific Registry of Transplant Recipients were linked with a national database of pharmacy claims. All adult patients on the liver transplant waitlist on January 1, 2014, or added to the list during 2014, with hepatitis C virus as reason for listing were identified (2009 patients). A subgroup of 1093 unique patients had consistent pharmacy claim capture and observations. We compared patients who were and were not treated with all sofosbuvir-based regimens. RESULTS: During the study period, 154 patients received sofosbuvir-based regimens. These patients had lower model for end-stage liver disease scores and significantly longer waiting times. We found a trend toward significance for more sofosbuvir-treated than untreated patients being removed from the waitlist due to improved condition (4.54% vs 3.19%, p=0.03). In a propensity score-adjusted analysis, sofosbuvir-treated patients were less likely to undergo transplant (hazard ratio 0.57, 95% confidence interval 0.37-0.89, p=0.01). CONCLUSION: During the study period reflecting early sofosbuvir use, few liver transplant candidates received sofosbuvir. Use was associated with lower incidence of transplant and a trend toward more waitlist removals due to improved condition.

Emergency Management of Malignancy-Associated Hypercalcemia.

The most common cause of hypercalcemia in the emergency department (ED) is malignancy-associated hypercalcemia (MAH), which can be caused by direct bone resorption from bone metastases, vitamin D secreting malignancies, and increased parathyroid hormone (PTH) or PTH-related protein (PTHrP) levels. Malignancy-associated hypercalcemia is associated with a very poor prognosis, with half of the patients dying within a month of diagnosis. Management consists of adequate hydration, bisphosphonate therapy, and correction of other abnormal electrolyte levels. Currently, no therapies have demonstrated an effect on mortality and are therefore viewed only as a means of stabilizing the patient until the underlying condition can be treated. All MAH patients should receive an oncology consult as soon as possible so they are able to receive treatment for the causative malignancy and increase their chance of survival.